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As published in Fire engineering Magazine.
By Steven Kanarian, MPH, Instructor CUNY, LaGuardia Community College Paramedic program e-mail: StevenKan@optonline.net
At 2:24 pm on a fall afternoon; paramedics and an engine company are dispatched to a call for a “child not breathing.” Dispatch stated that the mother caller said her “7-year-old child is not waking up, possibly not breathing.” Upon arrival the engine company and observe a 7-year-old boy lying on the couch. The patient’s head and shoulders are draped over the arm rest of the couch, and he barely notices the firefighters entering the room with their equipment and radio’s chirping. The patient has a vacant look, is very pale, diaphoretic and barely responds to painful stimuli.
“What happened?” Paramedic Miguel asks the mother. “He has been feeling ill since 11:00 o’clock. All of a sudden he had a seizure. It scared the life out of me to see my child like that” states the mother. “Does he have a history of seizures?” Miguel asks. “No, he only has mild asthma.” The first responder engine places the hi-concentration oxygen mask and ECG electrodes on the patient. With a little stimulation the patient’s respirations increase to 16.
Bob from the CFR company obtains vitals, “BP 150/100, 124 on the pulse, 16 on the resps, he responds to stimuli but is disoriented, pulse ox is 94%.” Bob puts a stethoscope to the boy’s chest, “clear and shallow bilaterally.” “Thanks brother”, Miguel replies.
Miguel asks the mother what parts of her son was shaking when he had the seizure, “his head went back and his arms were shaking up and down,” the mother explained. While showing how her son’s arms were positioned during the seizure she displays arms flexed and fists rotated inward during the seizure, classic decorticate posturing. Chris asks “how long did the seizure last?” “About 3 minutes” the mother informs the medics. “What was he doing before he got sick?” “He was playing video games all morning. He stopped at 11:00 o’clock and took a nap.” “Has he ever had seizures before or felt ill while playing video games?” Chris asks. “No, he plays those games all the time”.
Miguel asks his partner Chris, “What could cause a first time seizure in a 7-year-old with no history of seizures?” “Maybe trauma or an overdose” Chris answers. Chris then asks the mother if the boy possibly took any medications or poisons. No, I was watching him before and he slept on the couch. “Does he take any medications ma’am?” Chris asks. “A Proventil pump, he has asthma,” the mother replies. “Is he treated for any other medical problems?” “No”, states the mother. “Any allergies to medications?” “No” the mother replies. “Any recent injuries or falls?” “No” she replies.
As Chris begins to gather the equipment to start an IV, Miguel talks to his partner, “what could cause a seizure in healthy child?” Thinking back Miguel reviews the acronym OPQRST, “onset, duration, quality, radiation, severity and time.” to ensure they have obtained a complete history of present illness, and pertinent positives for seizures. Moving to the past medical history Miguel reviews SAMPLE. Miguel thinks, “Signs and symptoms, allergies, medications, past medical problems, last oral intake, and events leading up to the seizure. “What was the last thing he ate or drank?” “He ate around 7:00 am, he only had toast.” Thinking of past medical problems Miguel asks, “Ma’am, when was he in the hospital last?” He was in the hospital 3 weeks ago for nasal polyps.” “Did he stay overnight or just go to the emergency room?” He was there for 5 days, he had surgery, he had a nasal polyps removed.” “Do you have the discharge paperwork and instructions?” “Yes,” the mother digs the paperwork out of a pile in the kitchen table. “Here it is.” Miguel sees discharge instructions for surgery, discharge information about nasal polyps and a prescription for Augmentin. “Did you fill this prescription?” “No I have no insurance; they wanted $130.00 for those pills.” I am a part-time employee of the Parks Department. “Ma’am, Augmentin is a antibiotic which prevents infection. Your son may have an infection from his surgery.” Miguel thanks the mother for the information.
Miguel calls out from the kitchen, “Chris, Lieutenant, have everybody wear masks and gloves, he may have encephalitis or meningitis.” “Meningitis? Where did you pull that one out of Miguel?” “He was admitted for nasal polyps and never received antibiotics on discharge, could be an infection, encephalitis, sepsis or meningitis.” Miguel explains, “Good job, the lieutenant from the engine company states, “Gloves and goggles boys, and universal precautions.” “Chris and Miguel put on their N95 masks and start an IV normal saline lock. Chris samples the glucose level from the IV catheter. “His glucose level is 58, let’s get rolling, we can give him and Dextrose during transport.” When the child is sat upright to be transported he vomits yellow bile.
On route to the hospital the patient receives 0.5 gms / kg Dextrose 25% without improvement, the D25 is repeated. The child’s mental status does not change. Chris asks the child if he has any neck pain, the boy shakes his head weakly indicating no. Palpation of the posterior neck and flexing of the legs do not provoke pain indicative of meningeal irritation from meningitis.
Upon arrival at the hospital Miguel gives a presentation, including HPI, pertinent positives, PMH and vitals. The ED staff places the patient on Meningitis isolation precautions. After a 12-day stay in the hospital on antibiotics the boy is discharged.
Post-run review
Many of the seizure calls we respond to are in patients who have epilepsy. EMS providers regard seizure calls as routine and rely on standard diagnosis of epilepsy or febrile seizures. A response to a call for a lethargic 7-year-old child with a first time seizure is a significant incident that is sure to get the attention of even the most experienced fire department personnel. When responding to a medical emergency in a pediatric patient it is paramount to rapidly assess the child for life threatening problems, elicit a systematic history of present illness and past medical history.
Pediatric patient assessment begins with the “doorway” assessment. Upon entering a room with a pediatric patient we visualize the child to see if the patient is conscious and alert, or lethargic and apathetic. If a child’s does not respond to the fire department arriving with their equipment and radios chirping, there is probably a serious pathology causing altered mental status.
Assessment and Management of Pediatric Life Threats
The Pediatric Assessment Triangle (PAT) is the standard assessment tool for initial evaluation of the pediatric patient. The PAT consists of assessing the child’s appearance, breathing and circulation. Evaluating appearance includes assessing the patents muscle tone, mental status, interaction with the caregiver, consolability, gaze and speech. A quiet, lethargic child is a patient in need of immediate resuscitation. Evaluating breathing involves assessing the patency of airway, oxygenation, and ventilation. Assess airway by looking at body position, chest excursion, respiratory rate and effort and lung sounds. Sniffing position and tripod position are some of the hallmark signs of respiratory distress. Grunting and paradoxical respirations are ominous signs of respiratory failure. Assessment of the circulation reflects the adequacy of cardiac output and perfusion of vital organs. In assessing circulation of a pediatric patient we observe the skin color, end organ perfusion and level of consciousness. Mottled skin, restlessness and oliguria are signs of circulatory failure.
Using the PAT to gain an initial impression of the pediatric patient’s condition provide pre-hospital providers with a tool for a rapid size-up of a child’s potential life threats.
Once threats to life have been identified and treated, we can obtain a thorough history of present illness (HPI). A systematic HPI and physical are the keys to diagnosing the presenting medical problem and determining the correct course of treatment. Systematic collection of patient information leads to quality care. Most presenting problems are easy to determine and accepted at face value. Thorough pre-hospital care providers consider the obvious diagnosis then dig deeper to consider other possible diagnoses. The most interesting diagnoses, like this one of meningitis in a 7-year-old with a seizure, are made with a careful history and considering possible alternative diagnoses. Without a thorough history and considering the cause of the seizure the fire fighters, paramedics and hospital staff would have been unnecessarily exposed to meningitis and a prescription antibiotic. The case in this article was diagnosed using the information about the patient’s recent hospitalization and recent surgery, which was developed during the HPI, coupled with knowledge about the causes of altered mental status. When faced with a disoriented and lethargic child we must rule out the causes of AMS.
Presumptive Diagnosis Using “AEIOU-TIPPS”
The differential diagnosis of altered mental status in a patient can facilitated by using SAMPLE for the past medical history and the acronym AEIOU-TIPPS1 for reviewing the causes of AMS/Seizures. Systematic Assessment and HPI, PMH are essential to accurately and rapidly diagnose your patients. AIOU-TIPPS is a tool to consider all the causes of AMS / Seizures in addition to the first impression we form on the scene. As seen in the case presented, consideration of all causes of AMS resulted in better patient care and increased safety for the responders treating the child with meningitis.
The treatment of a patient in an emergency is performed rapidly by following a standard approach. Pre-hospital we use the initial impression and review of life threats to rapidly categorize and care for our patients. The acronym AEIOU-TIPPS can be useful in recalling the causes of AMS. AEIOU-TIPPS should be memorized or more practically, laminated and mounted in your drug bag for quick reference on the scene.
- Alcohol
- Epilepsy
- Infection
- Overdose
- Uremia
- Trauma
- Insulin
- Psychosis
- Poison
- Stroke
Febrile Seizures: The Familiar Diagnosis
EMS personnel may form a presumptive diagnosis of a child’s seizure as a febrile seizure because of a history of illness and rapid increase in fever. Febrile seizures occur in about 2% to 5% of children < 6-years of age; most occur at age 18-months to 6-years of age. Seizures are diagnosed as febrile after exclusion of other causes.2 Causes of AMS / Seizures from uremia, infection, lesions and electrolyte causes should be ruled out before assuming the patient has febrile seizures.
In this case presented with the 7-year-old male having seizures, the patient did not present with a fever and was more than 6 years of age, making he diagnosis of febrile seizure unlikely. Febrile seizure may be a dangerous assumption to rule out in a pre-hospital pediatric patient presenting with seizure and AMS. All the causes of seizures should be considered before a diagnosis of febrile seizures is made.
A More Serious Problem–Meningitis
In the case presented the recent history of surgery and lack of follow up with antibiotics was the key element that alerted the crew to the possibility of meningitis. Meningitis is an illness in which there is inflammation of the tissues that cover the brain and spinal cord. Viral or “aseptic” meningitis, which is the most common type, is caused by an infection with one of several types of viruses. In the United States, there are between 25,000 and 50,000 hospitalizations due to viral meningitis each year. 3 Staphylococcal meningitis can occur after penetrating head wounds or neurosurgical procedures. Bacterial meningitis is much more severe and can result in coma and death with a rapid onset.
Bacterial meningitis, which has a rapid onset and is much more severe, can result in coma and death. Or does only the one with a rapid onset result in death as you have it?
Meningitis occurs when an infection breaches the natural protection of the central nervous system. The blood supply of the meninges lies adjacent to the venous system of the nasopharynx, mastoid process, and middle ear. When the organism eludes the immune system and enters the cerebral circulation through one of these openings, infection spreads quickly through the subarrachnoid space. 4 Meningitis can occur with or without neck pain. Neck pain may be difficult to assess in younger children or those with AMS. Nuchal rigidity, which is neck stiffness with movement of the neck, may not be present in younger children. Verbal children will often complain of headaches and neck pain.
Meningitis can infect a patient with gradual or sudden onset. Gradual onset of meningitis is preceded by several days of lethargy, fever, GI, respiratory symptoms and increased irritability. Meningitis with rapid onset can present with shock, petechiae (small pinpoint red spots) purpuric spots (large purple or black spots), disseminated intravascular coagulation (DIC) and reduced levels of consciousness, frequently resulting in death within 24 hours.
Physical symptoms of patients with bacterial meningitis depend on the age of the patient, underlying medical condition and causative organism A respiratory illness or sore throat often precedes the more characteristic symptoms of fever, headache, stiff neck, and vomiting. Kernig’s and Brudzinski’s signs appear in about half of patients. In children, the presence of nuchal rigidity is a more reliable indicator of meningeal irritation than Kerning’s sign or Brudzinski’s sign. To detect nuchal rigidity in older children, ask them to sit upright and touch their chin to their chests. Younger children can be persuaded to touch their chin to their chest by following a small toy or light beam.5 Adults may become desperately ill within 24-hours, and children even sooner. Seizures occur in about 30% of patients. In patients > 2-years of age, changes in consciousness progress through irritability, confusion, drowsiness, stupor, and coma. 6
Management
Management of patient with meningitis begins with proper PPE by wearing gloves, mask and gown or BBP ensemble. In the management of a critical pediatric patient with meningitis attention to the PAT and life saving interventions such airway maintenance, suctioning, oxygenation and fluid resuscitation are important. In the AMS child administration of Dextrose 0.5 gms / kg will help establish normal glucose levels. In the event of seizure activity Diazepam or Midazolam can be given to stop seizure activity. Monitoring of the airway, ventilation assistance and intubation may be necessary following benzodiazepine administration.
Conclusion
The presenting case of a 7-year-old boy with new onset of seizure should appear as a serious call. We have discussed how important a detailed history of present illness, past medical history can be in making an accurate diagnosis. We also discussed the danger of incorrectly assuming a patient is having a febrile seizure. Proper PPE for pediatric patients having AMS and seizures is crucial for protecting EMS and public safety personnel responding to aid children. Febrile seizures are isolated seizures that can only be diagnosed following testing for infection and occur in children from 18-months of age to 6-years of age who have a fever. Use of the AEIOU-TIPPS acronym is useful in systematically considering all causes of AMS. By being diligent in detecting life threats, eliciting a thorough history and considering all the causes, we can help our patients. We must always be diligent in protecting ourselves and delivering high quality care to pediatric patients. The discerning and outstanding pre-hospital provider will always think, “It looks like this is the problem, what else should I consider?”
References
1. Caroline, Nancy. Emergency Care in the Streets, Jones and Bartlett Publishers. Sudbury, MA, 2008. Book 3, page 41-42.
2. Merck Manuals online Library. “Febrile Seizures”. http://www.merck.com/mmpe/sec19/ch283/ch283c.html obtained on 08/13/2008
3. Centers for Disease Control and Prevention. “Viral (“Aseptic”) Meningitis FAQs” http://www.cdc.gov/ncidod/dvrd/revb/enterovirus/viral_meningitis.htm obtained on 08/13/2008
4. Aehlert, Barbara. Comprehensive Pediatric Emergency Care, . Elsevier/Mosby.
St. Louis, MO. 2005.
5. Bates’ Guide to Physical Examination – 9th edition/ Bickley, Lynn S., Szilagyi., Lipincott Williams & Wilkens, 2007. Bates, page 751
6. Merck Manuals online Library. “Acute Bacterial Meningitis” http://www.merck.com/mmpe/sec16/ch218/ch218b.html obtained on 08/13/2008
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